An abortion clinic in Sharonville, Ohio, is at risk of being closed because of new state laws. / Tony Jones, The Cincinnati Enquirer

by Chrissie Thompson and Amber Hunt, The Cincinnati Enquirer

by Chrissie Thompson and Amber Hunt, The Cincinnati Enquirer

CINCINNATI -- Abortion restrictions tucked into Ohio's budget are threatening to close facilities around the state and leave 2.1 million people in the Cincinnati metropolitan area â?? Ohio's most populous â?? without an abortion clinic.

If the Cincinnati-area clinics were to close, the region would become the largest metropolitan area in the country without an abortion clinic, according to a Cincinnati Enquirer analysis cross-referencing U.S. Census data and abortion providers.

Ohio had 14 abortion clinics at the start of 2013 and could soon be down to seven. Three have closed so far this year â?? in Toledo, Cleveland and Akron â?? although those closures were mostly unrelated to the new state rules. Two other clinics, one in Toledo and one in Sharonville, are seeking reprieves from the Health Department's moves to revoke their licenses. And two more, in Cincinnati and Dayton, have asked the state to give them special permission to stay open.

At issue in several cases is a law passed in June as part of the state's two-year budget. The new rule prohibits abortion clinics from forming a patient-transfer agreement with a taxpayer-funded public hospital. State law classifies abortion clinics as outpatient surgery centers. By law, all such centers must have an agreement with a hospital that would accept the clinic's patients in an emergency.

The law forces abortion clinics to look to private hospitals for patient-transfer agreements. But many private hospitals, even those not affiliated with religious groups, won't enter into agreements with abortion clinics. And if they won't agree to accept an abortion clinic's patients, that clinic might have to close.

While nine states have transfer agreement laws, Ohio is the only state whose law limits what types of hospitals can enter into the arrangements, said Elizabeth Nash, state issues manager for the Guttmacher Institute, a New York research group that supports abortion rights.

Abortion-rights advocates and hospital administrators say the law is just a formality â?? that hospitals would never deny an abortion patient in an emergency. Nevertheless, it's the law, and it's leading to closures of abortion clinics around the state.

Those closures were expected. Before lawmakers passed the new rules, Ohio Right to Life publicized the University of Toledo Medical Center's transfer agreements with abortion clinics. Even before the law required it, the university decided its taxpayer-funded hospital system should not have such an agreement.

Toledo's abortion clinics lack other options. One has already closed, and the other is appealing the state's decision to revoke its license.

"We've had a state law on the books for years that said taxpayer dollars can't be used to pay for abortions. But for that public hospital, that abortion clinic would not be open to perform that abortion," said Mike Gonidakis, director of Ohio Right to Life, defending the new rules.

Still, other abortion clinics around the state had hoped the new law wouldn't affect them, even if hospitals pulled back on their transfer agreements. The Ohio Department of Health has the authority to approve "variances" for outpatient surgery centers, allowing them to stay in business without a patient-transfer agreement with a hospital. But two Southwest Ohio abortion clinics are the only outpatient surgery centers in the state to operate under variances in recent years, and the Health Department this fall refused to renew one of the variances, calling into question whether the practice will continue.

The continued use of variances is the source of hope for Planned Parenthood's Elizabeth Campbell Surgical Center in Mount Auburn. The clinic had a transfer agreement with UC Health. UC Health's charter allows it to be considered a private, nonprofit entity for legal purposes, even though it was set up in 2010 by the public University of Cincinnati.

But when the new transfer agreement law took effect on Oct. 1, the hospital terminated its transfer agreement with Planned Parenthood.

Hospital executives felt they didn't have a choice because of the way the law was worded, said Tony Condia, vice president of marketing at UC Health. It could be interpreted to mean that hospitals operated by a public entity, such as a university, are forbidden to enter into agreements with abortion clinics, he said.

Planned Parenthood approached several local hospitals about transfer agreements, to no avail, spokesman Rick Pender said.

Before the UC Health transfer agreement ended, Planned Parenthood applied for the special variance to stay in operation without a patient-transfer agreement with a hospital. The request is pending, and the clinic can legally operate while Director of Health Ted Wymyslo considers his decision, Health Department spokeswoman Tessie Pollock said.

"There are no irregularities in what we are doing," Pender said. "We have filed this variance agreement, as it is stipulated by the law, and there is no reason for it to be denied."

The situation is more dire for the Women's Med clinic in Sharonville, directed by Martin Haskell, the Cincinnati doctor who drew public attention to the controversial late-term abortion procedure sometimes called "partial-birth abortion."

Women's Med has been operating without a hospital transfer agreement since at least 2010 but had a variance from the Department of Health giving it permission to operate because its doctors could admit patients at Cincinnati hospitals. The variance was first granted under the Gov. Ted Strickland administration and then renewed by Wymyslo under the Gov. John Kasich administration, but Wymyslo last year moved to decline the variance. Women's Med has objected to the decision and awaits final order.

As of Thursday, the clinic was still taking appointments and seeing patients.

Jennifer Branch, a lawyer with Gerhardstein & Branch representing Women's Med, said the clinic requested transfer agreements from every hospital in the area, including Christ Hospital and Bethesda North, both of which are private.

None agreed to the arrangement, she said. Officials from Christ and Bethesda North didn't return phone calls seeking comment.

Haskell's other Ohio clinic, Women's Med in Dayton, has also operated under a variance. The Health Department is currently reviewing whether to renew that agreement.

"The entire western part of the state is in danger of losing access to safe, legal abortion care. And it's because of politics," said Kellie Copeland, executive director of NARAL Pro-Choice Ohio.

Without abortion clinics in Cincinnati and perhaps Dayton, Southwest Ohioans, Northern Kentuckians and even some Hoosiers would face hours of driving, days off work and gallons of gas to get an abortion â?? especially because Ohio law requires an appointment at a clinic at least 24 hours before an abortion, unless the woman is endangered by the pregnancy.

Nash, of the Guttmacher Institute, said the hardest hit by the limited access would be young women, poor women and women of color.

"We'd be in a place where women who have financial means will have access to care and women who are poor will have a difficult time accessing abortion services," Nash said.